March/April 2015

Treating the Elder Life Crisis
By Bill Thomas, MD, and Jennifer Tucker
Today's Geriatric Medicine
Vol. 8 No. 2 P. 22

Physicians must examine the possible root causes behind the behaviors and feelings older adults express, and determine how these concerns exert a negative impact on patients' quality of life.

Many older adults are coping with the symptoms of an elder life crisis. The phenomenon can occur when older adults experience feelings of loneliness, helplessness, and boredom. Physicians must be on the lookout for signs of this crisis and be prepared to help.

Often quality-of-life issues underlie the presenting reasons for patients to visit a geriatrician or primary care provider. While addressing these detrimental feelings is critical to older adults' overall well-being, many older adults are not comfortable discussing these issues with a physician. As people age and lose loved ones or their ability to enjoy simple pleasures independently, they can begin to suffer from an elder life crisis, which is not unlike a midlife crisis. The symptoms of this crisis, including a sense of powerlessness, withdrawal from pleasurable activities, and loss of independence, can result from illness or changes in physical capabilities.

As we age, it is healthful to embrace naturally occurring changes, including physical, mental, and social changes. However, withdrawal, apathy, moodiness, agitation, and aggression are not normal parts of aging that should simply be accepted. Rather, as health care providers, we need to look into the possible root causes behind behaviors and feelings that older adults express, and examine how these concerns exert a negative impact on patients' quality of life.

Not Found on a Prescription Pad
Unfortunately, physicians sometimes mistakenly believe there is nothing that can be done when the symptoms of an elder life crisis appear and write them off as untreatable aspects of a patient's life. It is sometimes true that in terms of straightforward medical treatment, nothing can be done to cure an individual of a specific disease. Yet physicians need to look to social workers, professional caregivers, and other forms of support as valuable tools in treating their patients' nontangible ailments. There are many nonmedical interventions that, when initiated by physicians, can positively impact patients' quality of life. Frequently, there is more at play than what can be addressed with a prescription pad.

In order to combat loneliness, people need to have easy and regular access to loving companionship in their lives, including friends, young children, family, or pets. When well-meaning caregivers, whether family members or professionals, do everything for an older adult who needs assistance with activities of daily living, rather than engaging that individual to become part of meeting his or her own needs, they may inadvertently create feelings of helplessness within that individual. Even a caregiving relationship can, and ideally, should involve both give and take, with both people learning, and growing with the other.

To imagine what this may look like, think of a woman with Alzheimer's disease teaching her youthful caregiver how to knit, or envision inviting a man in an assisted living facility to join you at the piano so he can sing for his neighbors and friends, or consider providing the materials for a woman to make gifts for her adult children as she had previously done. Introduce spontaneity into a patient's day with new scenery, friends, or activities, and it will help alleviate feelings of boredom in life.

While there is comfort in routines, there can still be room in life for unplanned interactions that have the potential to bring great joy. An easy way to visualize this is to picture a man going for a daily walk with a caregiver—a walk that takes place at the same time every day because that is when the caregiver is available. If the walk is taken on a slightly different route or an hour earlier or later, there is a chance the individual might walk past someone with a dog that might remind him of a dog he once had, and he will be enlivened by sharing this new story with his caregiver, who may in turn have a story about another dog to share.

Widen the Lens to Include the Team
When seeing a patient for any reason or complaint, it is essential for physicians to "widen the lens." It does a disservice to older adults in particular to view them through a narrow clinical focus. Developing a wider view requires one critical element: teamwork. It is simply not possible to take good care of older adults, even for the most highly skilled, dedicated, and caring physician, who is functioning alone in his or her office. Each physician must be connected to a sophisticated team of supporting professionals.

When a patient comes to a physician's office, the physician needs to look beneath the surface of any presenting complaint for something much deeper. In a model emergency department for older adults, one of the things taught to practitioners is that whatever the problem appears to be, there is always more to the story. So if a physician stops at the surface problem, then he or she is likely missing the things that matter the most. If a physician does not recognize that elder life crises exist, or that loneliness, helplessness, and boredom are problems that must be addressed, then he or she won't have the awareness to look for it or identify it.

A solid team of supporters—not simply other physicians and specialists to whom to refer patients—that might include family members, professional caregivers, social workers, and others, can contribute to maintaining the joy in an older adult's life by keeping the elder life crisis at bay. The job of a geriatrician is to be more globally focused on the well-being of a patient than a specialist might be. And with this broader goal of helping each patient maintain the highest quality of life rather than simply solving a specific medical ailment, geriatricians can realize that there is a need for many partners in an individual's care.

Diagnosing an Elder Life Crisis
Physicians must learn how to accurately diagnose an elder life crisis before collaborating with the team to provide an effective treatment plan. Diagnosing an elder life crisis is more complicated and nuanced than identifying typical chronic conditions associated with aging, such as diabetes or high blood pressure. Unfortunately, there is no single diagnostic or test on which to rely. Physicians and their teams must become intimately familiar with the key symptoms of an elder life crisis—loneliness, helplessness, and boredom—and the signs that a patient is experiencing them.

The initial signs of an elder life crisis are often masked by physical complaints, such as worsening arthritis pain, headaches, weight loss, or loss of appetite. Often these physical symptoms are accompanied by emotional symptoms that are more difficult for physicians to identify without a deeper knowledge of the patient, such as social withdrawal, loss of interest in hobbies, and diminished feelings of self-worth. It is imperative that physicians develop the skills to elicit additional information beyond physical ailments in order to zero in on the signs of an elder life crisis.

First and foremost, physicians must take the additional time necessary to know their patients and gain their trust. Assessments should be expanded to include key people in a patient's life, such as caregivers and family members, and include questions such as: How often does the patient leave home? What types of pleasurable pastimes does the patient enjoy? What is the extent of the patient's social circle? Knowledge in these areas will make it easier for physicians to encourage patients to open up about feelings that are characteristic of elder life crisis.

Treating a patient like a whole person and gaining a deeper knowledge of his or her life, social network, and daily habits is necessary for a physician and the care team to identify and address an elder life crisis.

A New Care Approach
Currently providers are doing their best with the system we have in place; however, the health care system is not equipped to adequately address an elder life crisis. Although the system is built around the acute needs of relatively young and healthy people, the reality is that this is not the primary population being served. Instead, we have a population with chronic care needs for a range of health problems such as dementia, diabetes, and obesity, and our current health care system does not do well with the complicated, overlapping, and sometimes contradictory needs of older adults with multiple diagnoses. Physicians need to think of themselves as agents of change rather than victims of a dysfunctional system.

Home care professionals are uniquely positioned to be part of an extended support system for which there is a dire need among the older population. Again, of course, it is critical to treat the health care issues and immediate needs of older adults, but their emotional needs, quality-of-life concerns, unique needs, and preferences are equally important to their overall well-being and cannot be overlooked.

An in-home caregiver with the appropriate training is equipped to provide engaging care rather than simply providing basic care, which may render a person helpless, and also has the potential to empower an older adult. Once engaged and offered the choice, an older adult can, if mentally and physically capable, take on a larger decision-making role in regard to his or her own health care. Each older adult who requires in-home care should have a care plan put in place by a trained and educated caregiver that addresses the older adult's unique interests and pleasures.

While home care is, in part, about keeping an individual safe in his or her own home, it is also about bringing joy and quality of life to older adults in small ways. Take, for example, a 90-year-old woman who has Alzheimer's disease and wants to continue to enjoy her daily cup of coffee each morning. This woman, Elsa, from Eastern Europe, grew up around the aromas of freshly brewed coffee. She has enjoyed drinking it throughout her adult life. Now, Elsa lives alone and her adult daughter has hired live-in help for her while she is at work. Elsa's caregiver became concerned about her coffee-making attempts as she spilled water and mishandled a hot coffee pot on the stovetop. Rather than removing the tools needed to make coffee, or denying her coffee altogether, the caregiver introduced a one-cup brewer, so Elsa simply had to push one button and could make herself coffee before the caregiver arrived each day. As a result, Elsa was not helpless in her own home. She could continue to partake in a simple daily pleasure despite her memory loss and physical limitations.

These types of considerations are part of a care plan that starts by asking, "Who are you?" and not, "What is wrong with you?" or "What can't you do?" or "What is your disease?" The care plan—which, of course, includes details on necessary medical, dietary, and physical needs—stays in the home with the in-home care client as a way for those providing care to see what activities this person enjoys and what activities they can do together.

Be the Change
Physicians can be at the forefront of changing aging for their patients and for themselves, by becoming aware of the elder life crisis and developing crucial, collaborative support teams. No one should be left helpless, bored, or lonely at any age.

The reality is that with the increasing lifespans of the aging population worldwide, medicine and acute care is not the be-all, end-all solution. Instead, what we know is that in-home care—whether provided by family members or professional trained caregivers—is already a necessary part of life for those who need assistance with daily activities.

We can all become educated in recognizing the symptoms of an elder life crisis, and then seek out those best qualified to alleviate it. Start today by thinking about quality of life and what this means for those you treat and provide care for on a routine basis. Broaden the lens on how you view the people you care for to include an awareness of the elder life crisis. Let the goal be helping each person to live a good life.

— Bill Thomas, MD, based in Ithaca, New York, is cofounder of The Eden Alternative, creator of The Green House Project, and author of Second Wind: Navigating the Passage to a Slower, Deeper, and More Connected Life.

— Jennifer Tucker is vice president of Homewatch CareGivers in Greenwood Village, Colorado.